Health Care Policy and Politics A to Z


Julie Rovner

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      Insanity has been defined as doing the same thing over and over and expecting a different result. By that logic, everyone who has been working to overhaul the U.S. health care system during the past four decades is insane—including me. The publication of this third edition of Health Care Policy and Politics A to Z is timed to coincide with another predicted effort—the first since President Bill Clinton's failed attempt in the 1990s—to enact major changes in how health care is financed and delivered in the United States.

      Whether or not that debate produces results—or even materializes—much has happened on the health policy front since the last edition to warrant an update of this volume. A new and controversial prescription drug benefit for Medicare was passed and implemented, Massachusetts mandated health insurance for all its citizens, and Tennessee eliminated coverage for hundreds of thousands of its residents. Many health issues remain stubbornly unresolved or have simply grown larger. As of this writing, forty-seven million Americans lacked health insurance, the nation's annual tab for health spending topped $2 trillion, and arguments over such sensitive social issues as abortion and euthanasia appeared no more amenable to compromise.

      Yet I remain as fascinated as ever covering health policy, my professional focus since 1986. Health policy never gets boring, in part because while the big problems persist, many of the smaller issues keep changing. Who could have predicted in 1986 that little more than a decade later Congress would be debating such issues as a ban on the cloning of humans or discrimination based on genetic make-up? Or that fifteen years later national discussions would focus on the relative risks and benefits of the smallpox vaccine?

      Unlike many of the issues that receive attention in Washington, D.C., health care affects all Americans, and it affects them in life-or-death ways. But health policy, like health care in general, is dauntingly complicated, rife with jargon and long-running conflicts that have continued for years or even decades. People who want to learn more about Medicare reform, to name just one example, are often put off by conversations that seem to take place in another language or by experts who presume that everyone knows as much as they do about the program's history and the controversies that have surrounded it. Meanwhile, politicians are frequently able to take advantage of the public's lack of knowledge about important programs such as Medicare to engage in unchecked demagoguery.

      This volume provides background on many health issues on the national agenda. It presumes at least a high school civics class understanding of how the federal government works but no expertise in health care. Its intended audience is advanced high school and college students, professional government-watchers new to health policy, and people who want to be better able to follow the news.

      Although many books and glossaries define health care terms, this one focuses comprehensively on health policy issues in all their dimensions, including their histories. This kind of information is more difficult to come by than definitions—and more valuable because it can enable more citizens to join the national conversation about the direction of health care policy.

      This work is also “Congress-centric” because, for better or worse, the U.S. Congress is where much of the nation's health policy is made. While those who rail against “big government” campaign to prevent the federal government from becoming more involved in the nation's health care system, the federal government continues to provide, by nearly any measure, the single largest share of funding for health care. In 2006 the federal government paid just under $450 billion of the nation's $2.1 trillion health care bill, a little less than a quarter of the total. Congress, as the holder of the federal purse strings, naturally wants to determine the policies that accompany those dollars.

      Even though health care, according to pollsters, is usually among voters’ top concerns, it has in the past commanded surprisingly little respect among policy makers, compared with such issues as taxes, trade, and national security. That is likely to change in the near future. The inexorable aging of the massive baby boom generation will bring health care issues front and center, because older people consume more health care resources than younger people. The financial future of Medicare is just one item on a long list of issues related to the aging “boomers” with which Congress will have to grapple. New technology is also driving current and future health policy. The ability to do new and marvelous things often prompts significant ethical questions—and creates the need to set new spending priorities. Finally, rapid changes in the private health care marketplace are not going unnoticed by lawmakers, if only because dislocations are prompting complaints from constituents and driving the number of uninsured Americans ever higher.

      In the decade since the first edition of this book was published, scientists have isolated stem cells from human embryos and elsewhere and finished mapping the human genome, heralding the possibility of entirely new lines of treatment for dozens of ailments that have confounded medical professionals for generations. At the same time, fears about bioterrorism have led to new efforts to prepare for the possibility of outbreaks of ailments once thought conquered, such as smallpox. Further, the emergence of new diseases such as severe acute respiratory syndrome, or SARS, have served as a reminder that freedom from disease is an elusive goal.

      Policy debates have also advanced. Lawmakers have tried to address what some have called an epidemic of medical mistakes; health care inflation has returned in force, leading to new efforts to control costs; and the number of Americans without any health insurance has remained stubbornly high. Efforts to remedy this short fall are hampered by the ideological divide between those who would have the government exercise most of the control in any program and those who favor a private sector solution.

      Health policy is an ever-changing issue; as the content of health policy debate continues to evolve, so will this book. Any mistakes or omissions are mine alone, and suggestions for future editions will be gratefully accepted.

      A Note on Sources

      The majority of the information in this book comes directly from my own reporting: seven years covering health and welfare for the Congressional Quarterly Weekly Report, ten years for National Journal's Congress-Daily, and ten years for National Public Radio.

      In compiling this volume I made liberal use of my own previously published material, particularly that from CQ Weekly Reports and Almanacs. Other information was drawn from reports prepared or funded by the Commonwealth Fund, the Henry J. Kaiser Family Foundation, the Robert Wood Johnson Foundation, the Employee Benefit Research Institute, the Alliance for Health Reform, and the Urban Institute.

      I am also indebted to the public affairs staffs of several organizations, particularly the Department of Health and Human Services, the Centers for Medicare and Medicaid Services, the American Medical Association, and America's Health Insurance Plans, which provided more background papers and materials than I can enumerate here.


      Learning an area as complex and diverse as health policy requires many teachers, and I am privileged to have been taught by some of the best. I especially want to thank the following people, many of them current or former Capitol Hill staff aides, for their patient explanations and unfailing availability on deadline, often provided at the expense of sleep following days or even weeks of around-the-clock drafting or negotiation sessions.

      Medicare experts include the following former Hill staff: David Abernethy, Brian Biles, Mike Hash, Chip Kahn, Tricia Neuman, Karen Pollitz, Bill Vaughan, and Marina Weiss. Off the Hill, Diane Archer, Marty Corry, Geri Dallek, Karen Davis, Judy Feder, Ed Howard, Marilyn Moon, Ron Pollack, John Rother, Patricia Smith, and Gail Wilensky provided invaluable background.

      I learned Medicaid at the knee of three of the most formidable experts in the field: Sara Rosenbaum, Diane Rowland, and Andy Schneider. Also adding to my understanding were Howard Cohen and Karen Nelson of the House Energy and Commerce Committee.

      David Schulke and Chris Jennings, formerly of the Senate Aging Committee, taught me the intricacies of prescription drug prices and other issues concerning the Food and Drug Administration. Tobacco experts Matt Myers and Cliff Douglas were invaluable in helping me understand that complicated issue. Chai Feldblum and Pat Wright helped me through the debates over the Americans with Disabilities Act. Of the many people who guided me through the abortion debates on Capitol Hill, Rachel Gorlin, Jo Blum, Susan Cohen, and Douglas Johnson stand out as those I could not have done without.

      Although I am grateful to all of my sources, two of them—Tim Westmoreland, formerly of the House Energy and Commerce Committee and now at Georgetown University Law Center, and David Nexon, formerly of the Senate Health, Education, Labor, and Pensions Committee—most influenced my thinking and understanding on a wide range of health issues, from Acquired Immune Deficiency Syndrome (AIDS) to insurance coverage to public health programs.

      At CQ Press, I want to thank Dave Tarr for suggesting the idea for the book and for sponsoring the development of the first edition and, for this edition, Marc Segers, Andrew Boney, and Emily Bakely. Finally, I want to thank my editors at National Public Radio: Anne Gudenkauf and Joe Neel, who were so cooperative in putting up with me while I was working on this project in my “spare” time.

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